Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to apply a vehicle safety restraint during transportation in the
facility van for one of three (R1) residents reviewed for falls on the sample list of three. This failure resulted
in R1's wheelchair flipping backwards in the facility van during transport and R1 sustained a left side rib
fracture.
Findings Include:
The Motor Vehicle Safety Program dated January 2025 documents seat belts and shoulder harnesses
(occupant restraint systems) must be worn or used whenever the vehicle is in operation. The vehicle may
not move until all passengers have fastened their restraints.
R1's Fall Follow-up Note dated 5/15/25 documents R1 fell from his wheelchair while in the facility van. R1
was being transported back to the facility and his wheelchair was not properly secured. The root cause of
the fall was determined to be the wheelchair was not properly secured.
R1's Incident Note dated 5/12/25 documents R1 sustained a fall at 6:20 PM in the facility van. R1 is alert
and orientated to person, place, time, and situation. R1 is rating new onset pain at a 5/10.
R1's Progress Note dated 5/13/25 documents V5 Nurse Practitioner was called to evaluate R1 due to
accident the day before. R1 was sitting at the nurses' station in his wheelchair complaining of pain in the
neck and upper back radiating to the rib area. R1 stated the pain was not controlled by Acetaminophen. V5
requested R1 to be sent to the emergency room for evaluation.
R1's Progress Notes document multiple requests for pain medication due to rib pain after the accident on
5/12/25.
R1's Progress Note written by V5 Nurse Practitioner dated 5/13/25 documents V5 assessed R1 after a fall
with a head strike. R1 complained of neck pain, headache, bilateral eye redness, and rib/chest wall pain. R1
was alert and orientated. R1 indicated when he fell backwards in the van in his wheelchair, he struck his
head and blacked out. R1 reported having to deal with a headache and neck pain since the accident. R1
described the pain as bad and throbbing. V5 sent R1 to the emergency room.
R1's emergency room documentation dated 5/13/25 documents R1 had a fall in his wheelchair which
resulted in a closed head injury and closed left side rib fracture. On 5/12/25 R1 was loaded into the facility
van in his wheelchair for transport. The facility driver did not strap in R1's wheelchair. When the driver hit the
gas R1's wheelchair flipped backwards causing him to fall from his
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145371
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145371
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Bloomington
1509 North Calhoun Street
Bloomington, IL 61701
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Actual harm
Residents Affected - Few
wheelchair. R1 woke up on 5/13/25 with continued chest wall pain and head and neck pain. The
documented clinical assessment documents chest wall tenderness is present which correlates with the
radiology report.
R1's Radiology Report of the Chest dated 5/13/25 documents R1 sustained a possible non-displaced acute
fracture of the left lateral rib number six and clinical correlation is advised.
R1's Medical Diagnoses list dated May 2025 documents R1 is diagnosed with Dementia, Major
Depression, and Obesity.
R1's Minimum Data Set, dated [DATE] documents R1 is mildly cognitively impaired, requires
supervision/touching assistance from staff to safely transfer from a seated position, and requires the use of
a manual wheelchair for mobility.
R1's Medication Administration Records for May 2025 documents prior to the accident on 5/12/25, R1 did
not request any as needed pain medication. After R1's wheelchair flipped backwards in the van when being
transported, R1 requested pain medication (Tylenol) daily. A new as needed pain medication (Tramadol 50
milligrams) was also added for R1's rib pain on 5/14/25 and then the frequency was increased from every
six hours to every eight hours on 5/20/25. R1 has been taking pain medication regularly since the accident.
On 5/24/25 at 12:55 PM R1 stated two staff members (V7 Certified Nurse's Assistant) and (V8 Licensed
Practical Nurse) came to pick him up from the hospital. R1 stated V7 loaded him in his wheelchair into the
facility van. R1 stated she did not provide him with a seatbelt or strap his wheelchair in with the van safety
strap system. R1 stated they began to drive and stopped at a stop light. R1 stated as R1 took off from the
red light, R1's wheelchair flipped backwards, and he fell back and hit his head. R1 stated the fall hurt his
head, neck, and he felt it all through his body. R1 stated he has been having pain ever since the accident
and for the first two days it was hard for him to get out of bed. R1 stated he has had chest wall pain on both
sides, but it often hurts more on the right side. R1 stated he was sent to the emergency room the day after
the accident, and they told him he had a fractured rib. R1 stated before the accident he rarely had pain but
since the accident he has had pain every day mostly in his chest when he breaths more deeply. R1 stated
he went from not taking any pain medication to taking pain medication every day.
On 5/24/25 at 1:04 PM V8 Licensed Practical Nurse stated she went with V7 Certified Nurses Assistant
(CNA) in the facility van to go pick up R1 from the hospital. V8 stated when V7 started driving after stopping
at a red light, R1's wheelchair flipped backwards and R1 was on his back. V8 stated her and V7 helped get
R1 back in his wheelchair in the van and they took him back to the facility. V8 stated R1 complained of a
headache at the time. V8 stated she was never trained on how to properly secure a resident in the van for
transport.
On 5/24/25 at 1:31 PM V7 Certified Nurses Assistant (CNA) stated she was asked to pick up R1 from the
hospital on 5/12/25. V7 stated she had transported residents before however V7 stated she had never been
trained on how to properly secure residents in wheelchairs in the facility van. V7 stated as she drove back
to the facility, R1's wheelchair flipped backwards, and he was on his back on the floor of the van. V7 stated
she went back to check on R1 and he stated he felt like he was having a heart attack, his neck, head, and
chest hurt. V8 helped get R1 back into the wheelchair and they returned to the facility. V7 stated the
accident happened about 6:20 PM and R1 continued to complain of chest wall, head, and neck pain for the
rest of her shift which ended at 10:00 PM.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145371
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145371
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Bloomington
1509 North Calhoun Street
Bloomington, IL 61701
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Actual harm
On 5/24/25 at 3:45 PM V2 Director of Nurses (DON) confirmed V7 and V8 failed to properly secure R1 in
the wheelchair during transport in the facility van on 5/12/25. V2 confirmed this caused R1's wheelchair to
flip backwards during transport. V2 confirmed R1 has had pain on his chest wall since the accident and the
radiology scan completed on 5/13/25 documents R1 sustained a possibly acute left sixth rib fracture.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145371
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the May 24, 2025 survey of ARCADIA CARE BLOOMINGTON?
This was a inspection survey of ARCADIA CARE BLOOMINGTON on May 24, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ARCADIA CARE BLOOMINGTON on May 24, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.